Healthcare Provider Details

I. General information

NPI: 1205842101
Provider Name (Legal Business Name): WAYNE SMITH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3210 EAGLE RUN DR NE STE 100
GRAND RAPIDS MI
49525-7051
US

IV. Provider business mailing address

PO BOX 1847
MUSKEGON MI
49443-1847
US

V. Phone/Fax

Practice location:
  • Phone: 616-279-3725
  • Fax:
Mailing address:
  • Phone: 231-672-4900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101011102
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number5101011102
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: